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Waste Tire Su' ;y & Inspection Report inspection ReportNumber <br /> State of California <br /> CWMB ew 04104) <br /> California Integral dt81 Waste Management Board Survey Form - Page 1 Il - 1140965 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ Inspection Type (Fill one) <br /> Site Suffix: d 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> W1 <br /> I Business or Facility Name Inspected By Inspector <br /> Physical ddress <br /> JInspection Date Q / <br /> tom, gs;�os' Time In Time Out <br /> Business Rep Title /t O AM O AM <br /> X -storage <br /> 0 PM C� 3 PM <br /> Operational Status j Tire Type Business Role Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ,;Z s' <br /> 0 Active 0 Closed 0 Passenger ® Generator ® Outdoor <br /> D <br /> > > <br /> Latitude 0 Altered <br /> GPS 0 Hauler ® Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V � A HAULING AND_MANIFEST REQUIREMENTS ® Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956- Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Datet t f / / I C7 <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 <br /> § <br /> 0 0 Other: Q.fp Compliance r ft > <br /> L <br /> Comments <br /> ilvaS <br /> Inspection Form Included: 0 <br /> Comments Included: !:Spector's Signa e.- - (Business Rep's Signature hone NumberPhone Number <br /> INSTRUCTIONS ON BACK Cora Incorr <N �/; E'X 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pin Cop .LEA <br />